Background: Tuberculosis (TB) and hepatitis are the two common co-infections in patients infected with human immunodeficiency virus (HIV). Anti-tuberculosis treatment (ATT) may have an effect on the liver enzymes in these co-infected HIV patients.
Aims: To determine the prevalence of Hepatitis B and C virus coinfection in HIV infected patients in Tamilnadu and assess effects of anti-tuberculosis drugs on their liver function.
Settings: HIV positive subjects referred to the Tuberculosis Research Centre, Chennai
Materials and Methods: All HIV infected patients referred to the Tuberculosis Research centre, from March 2000 to May 2004, were screened for Hepatitis B surface antigen (HBsAg) & Hepatitis C virus (HCV) antibodies by enzyme linked immunoabsorbent assay (ELISA). HIV infection was confirmed using two rapid tests and one ELISA. Patients were given either short- course anti-tuberculosis treatment or preventive therapy for tuberculosis, depending on the presence or absence of active TB, if their baseline liver functions were within normal limits. None of these patients were on antiretroviral therapy during the study period.
Statistical Analysis: Paired t-test was used to find the significance between baseline and end of treatment liver enzymes levels, while logistic regression was done for assessing various associations.
Results: Of the 951 HIV-infected patients, 61 patients (6.4%) were HBsAg positive, 20 (2.1%) had demonstrable anti HCV antibodies in their blood. Serial estimation of liver enzymes in 140 HIV patients (81 being co-infected with either HBV or HCV) showed that 95% did not develop any liver toxicity while they were on anti-tuberculosis treatment or prophylaxis.
Conclusions: The prevalence of hepatitis B and C coinfection was fairly high in this largely heterosexually infected population supporting the use of more careful screening for these viruses in HIV positive persons in this region. Anti-tuberculosis therapy as well as TB preventive therapy can be safely employed in HIV and hepatitis coinfected patients, if baseline liver function tests are within normal limits.

The psychosocial impact of disasters has attracted increasing attention. There is little consensus, however, about what priorities should be pursued in relation to mental health interventions, with most controversy surrounding the relevance of traumatic stress to mental health. The present overview suggests that acute traumatic stress may be a normative response to life threat which tends to subside once conditions of safety are established. At the same time, there is a residual minority of survivors who will continue to experience chronic posttraumatic stress disorder (PTSD) and their needs can be easily overlooked. The ADAPT model offers an expanded perspective on the psychosocial systems undermined by disasters, encompassing threats to safety and security; interpersonal bonds; systems of justice; roles and identities; and institutions that promote meaning and coherence. Social reconstruction programs that are effective in repairing these systems maximize the capacity of communities and individuals to recover spontaneously from various forms of stress. Within that broad recovery context, clinical mental health services can focus specifically on those psychologically disturbed persons who are at greatest survival risk. Only a minority of persons with acute traumatic stress fall into that category, the remainder comprising those with severe behavioural disturbances arising from psychosis, organic brain disorders, severe mood disorders and epilepsy. Establishing mental health services that are community-based, family-focused and culturally sensitive in the post-emergency phase can create a model that helps shape future mental health policy for countries recovering from disaster.

Complex emergencies (CEs) have been the most common human-generated disaster of the past two decades. These internal conflicts and associated acts of genocide have been poorly understood and poorly managed. This article provides an epidemiological background and understanding of developing and developed countries, and chronic or smoldering countries' CEs, and explains in detail the prevailing models of response seen by the international community. Even though CEs are declining in number, they have become more complex and dangerous. The UN Charter reform is expected to address internal conflicts and genocide but may not provide a more effective and efficient means to respond.

Background: Gabapentin is an antiepileptic drug. Its antiemetic effect is demonstrated in chemotherapy-induced acute and delayed onset of nausea and vomiting in breast cancer patients.
Aim: To evaluate the antiemetic effect of gabapentin on incidence and severity of postoperative nausea and vomiting in laparoscopic cholecystectomy.
Settings and Design: Double-blind, randomized, placebo-controlled study.
Materials and Methods: Two hundred and fifty patients of ASA physical status I and II, scheduled for laparoscopic cholecystectomy were randomly assigned into two equal groups to receive 600 mg gabapentin or matching placebo two hours before surgery. Standard anaesthesia technique was used. Fentanyl was used as rescue postoperative analgesic. Ondansetron 4 mg was used intravenously as rescue medication for emesis. The total number of patients who had nausea or vomiting, and its severity and total fentanyl consumption in the first 24 hours were recorded.
Statistical Analysis: "Z test" was used to test the significance of severity of post-operative nausea and vomiting between groups. Fentanyl consumed in each group (Mean±SD) within 24 hrs was compared using student t test. P value< 0.05 was considered significant.
Results: There were no demographic difference between the two groups. Incidence of post-operative nausea and vomiting within 24 hrs after laparoscopic cholecystectomy was significantly lower in gabapentin group (46/125) than in the placebo group (75/125) (37.8% vs 60%; P =0.04). There was a significantly decreased fentanyl consumption in gabapentin group (221.2±92.4 µg) as compared to placebo group (505.9±82.0 µg; P =0.01).
Conclusion: Gabapentin effectively suppresses nausea and vomiting in laparoscopic cholecystectomy and post-operative rescue analgesic requirement.

As terrorists attacks increase in frequency, hospital disaster plans need to be scrutinized to ensure that they take into account issues unique to weapons of mass destruction. This paper reports a review of the literature addressing hospital experiences with such incidents and the planning lessons thus learned. Construction of hospital disaster plans is examined as an ongoing process guided by the disaster planning committee. Hospitals are conceived as one of the components of a larger community disaster planning efforts, with specific attention devoted to defining important linkages among response organizations. This includes the public health authorities, political authorities, prehospital care agencies, and emergency management agencies. A review is completed of six special elements of weapons of mass destruction incidents that should be addressed in hospital disaster plans: incident command, hospital security, patient surge, decontamination, mental health consequences, and communications. The paper closes with a discussion of the importance of training and exercises in maintaining and improving the disaster plan.

This case report is about a past smoker who presented with history of recurrent ulcers and digital gangrene with claudication pain of the left foot for the past fifteen years. Clinical examination and angiogram showed disease involving the peripheral vessels of lowervlimb. This patient had been labeled as Buerger's disease 15 years ago based on clinical and demographic profile of the illness. We felt that the progression of the disease despite the patient having stopped smoking 15 years ago along with the presence of elevated inflammatory markers in the blood with proteinuria was not in keeping with the nature of the disease. Furthur evaluation revealed that the patient had systemic lupus erythematosus with antiphospholipid antibody syndrome. This case highlights the need for a careful search for diseases, which can mimic Buerger's disease in young smokers who present with peripheral vascular disease and who have an atypical clinical presentation or progression.

A shift from significance test to hypothesis test through power analysis in medical researchGirish SinghApril-June 2006, 52(2):148-150PMID:16679686

Medical research literature until recently, exhibited substantial dominance of the Fisher's significance test approach of statistical inference concentrating more on probability of type I error over Neyman-Pearson's hypothesis test considering both probability of type I and II error. Fisher's approach dichotomises results into significant or not significant results with a P value. The Neyman-Pearson's approach talks of acceptance or rejection of null hypothesis. Based on the same theory these two approaches deal with same objective and conclude in their own way. The advancement in computing techniques and availability of statistical software have resulted in increasing application of power calculations in medical research and thereby reporting the result of significance tests in the light of power of the test also. Significance test approach, when it incorporates power analysis contains the essence of hypothesis test approach. It may be safely argued that rising application of power analysis in medical research may have initiated a shift from Fisher's significance test to Neyman-Pearson's hypothesis test procedure.

Background: HIV/AIDS pandemic brought into focus the importance of safe blood donor pool.
Aims: To analyze true seroprevalence of HIV infection in our blood donors and devise an algorithm for donor recall avoiding unnecessary referrals to voluntary counseling and testing centre (VCTC).
Materials and Methods: 39,784 blood units were screened for anti-HIV 1/2 using ELISA immunoassay (IA-1). Samples which were repeat reactive on IA-1 were further tested using two different immunoassays (IA-2 and IA-3) and Western blot (WB). Based on results of these sequential IAs and WB, an algorithm for recall of true HIV seroreactive blood donors is suggested for countries like India where nucleic acid testing or p24 antigen assays are not mandatory and given the limited resources may not be feasible.
Results: The anti-HIV seroreactivity by repeat IA-1, IA-2, IA-3 and WB were 0.16%, 0.11%, 0.098% and 0.07% respectively. Of the 44 IA-1 reactive samples, 95.2% (20/21) of the seroreactive samples by both IA-2 and IA-3 were also WB positive and 100% (6/6) of the non-reactive samples by these IAs were WB negative. IA signal/cutoff ratio was significantly low in biological false reactive donors. WB indeterminate results were largely due to non-specific reactivity to gag protein (p55).
Conclusions: HIV seroreactivity by sequential immunoassays (IA-1, IA-2 and IA-3; comparable to WHO Strategy-III) prior to donor recall results in decreased referral to VCTC as compared to single IA (WHO Strategy-I) being followed currently in India. Moreover, this strategy will repose donor confidence in our blood transfusion services and strengthen voluntary blood donation program.

The challenge of preparation for a chemical, biological, radiological or nuclear terrorist attackDavid A Alexander, S KleinApril-June 2006, 52(2):126-131PMID:16679677

Terrorism is not a new phenomenon, but, in the contemporary scene, it has established itself in a manner which commands the most serious attention of the authorities. Until relatively recently, the major threat has been through the medium of conventional weaponry and explosives. Their obvious convenience of use and accessibility guarantees that such methods will continue to represent a serious threat. However, over the last few years, terrorists have displayed an enthusiasm for higher levels of carnage, destruction and publicity. This trend leads inexorably to the conclusion that chemical, biological, radiological and nuclear (CBRN) methods will be pursued by terrorist organisations, particularly those which are well organised, are based on immutable ideological principles, and have significant financial backing. Whilst it is important that the authorities and the general public do not risk over-reacting to such a threat (otherwise, they will do the work of the terrorists for them), it would be equally ill-advised to seek comfort in denial. The reality of a CBRN event has to be accepted and, as a consequence, the authorities need to consider (and take seriously) how individuals and the community are likely to react thereto and to identify (and rehearse in a realistic climate) what steps would need to be taken to ameliorate the effects of such an event.

The non-invasive method of blood pressure measurement is regarded as a safe procedure and the reports of any serious complications are rare. We report a unique case of extensive skin necrosis due to an intermittently inflating blood pressure cuff in a 65-year-old critically ill lady following a third time redo mitral valve surgery. A brief review of the literature on complications associated with noninvasive method of measurement of blood pressure is presented along with possible mechanisms of skin injury and ways to avoid it.

Background : Signs of Inflammation in Children that can Kill (SICK score) is a new severity-of-illness score. It uses the physical signs of the Systemic Inflammatory Response Syndrome (SIRS) and its continuum - the Multiple Organ Dysfunction Syndrome (MODS). The development of the score used multiple logistic regression model coefficients converted to integer scores that have been published earlier.
Aims: The present study was done to validate the scoring system by predicting outcomes in a fresh data set.
Setting: Intensive care unit in a tertiary referral hospital
Design: Prospective
Materials and Methods: 125 admissions to the intensive care unit were evaluated so that the SICK score and the PRISM score could be calculated. In-hospital mortality was noted
Statistical Analysis: Calibration (Hosmer-Lemeshow goodness of fit) and discrimination (area under the ROC curve) were used to measure performance.
Results: Of the 125 patients studied 23 died. The area under the ROC curve was 0.76 compared to 0.80 in the development sample. Using PRISM in the validation group, the ROC was 0.78. Calibration was excellent.
Conclusion: The SICK score can predict severity of illness with nearly the same accuracy as the PRISM score. The SICK score can be calculated immediately on admission and can help to prioritize care for the more sick children who need urgent aggressive management. Larger studies, that includes all admissions to the hospital, will now need to be done.

Mucormycosis is unusual in surgical practice. Awareness of the classical findings leads to early detection. Excisional therapy whenever possible along with systemic antifungal treatment is the key to successful outcome. A 70 year old female, a known case of diabetes mellitus and chronic obstructive pulmonary disease, on inhalational steroids and oral hypoglycemic agents, presented to us with complaints of sudden onset pain, redness and swelling of left breast. A diagnosis of severe mastitis was made and a release incision was taken. The entire breast became gangrenous in next 24 hours and simple mastectomy had to be performed as a life saving measure. Histopathology revealed mucormycosis of breast. To the best of our knowledge this is the first reported case of mucormycosis of breast in the English literature.